Anyone who knows any physicians in practice these days knows that doctors are feeling pressured on all sides, as their organizations implement and optimize electronic health records (EHRs), move forward to comply with the meaningful use requirements under the Health Information Technology for Economic and Clinical Health (HITECH) Act, prepare to transition to the new ICD-10 coding system, and fulfi ll diverse requirements related to the mandatory and voluntary programs under the Aff ordable Care Act (ACA). Indeed, for many doctors, it all feels like too much, and physician documentation is front and center when it comes to what’s frustrating them on a moment-to-moment basis.
It feels like a perfect storm, doesn’t it? Already-time-pressured physicians feel pushed to satisfy numerous different types of requirements. Given that many are already impatient with documenting within the physician documentation systems embedded in EHRs, those doctors, who often have received only minimal training in electronic documentation, create messy progress notes, using the copy-and-paste and copy-and-forward capabilities within EHR systems that readily enable “note bloat,” with the equivalent of many pages of paper notes ballooning across computer screens nationwide.
Yet CMIOs, CIOs, and others say that a combination of lack of good training and organizational discipline, confusion over increased documentation requirements, and a dose of urban legend are leading to the false belief on the part of practicing physicians that note bloat is inevitable. Instead, the industry leaders are helping doctors to rethink how and why they document, with sometimes startlingly effective results. And CMIOs are at the center of progress in this area.
“There’s a lot that we can do in how we structure notes in the EHR; it’s all too easy to pull a ton of information into the daily progress note, and a lot of that is not needed,” says Brian Patty, M.D., vice president and CMIO at the four-hospital, 650-bed HealthEast Health System, based in St. Paul, Minn. “Just training physicians to structure their notes to be more succinct helps.” What’s more, Patty says, “What I really tell physicians is, if your note isn’t viewable on a single screen. We’re trying to get them to provide more pertinent information; and we spend a lot of time designing our notes.” Patty and his CMIO colleagues at progressive patient care organizations nationwide are in fact beginning to take action to reform physician documentation for the new healthcare.
Pushing for note reform in Pittsburgh
One organization in which the push towards MD documentation reform is already far along is the 20-plus-hospital University of Pittsburgh Medical Center (UPMC) health system in Pittsburgh. “You have to socialize this,” says G. Daniel Martich, M.D., vice president and CMIO of UPMC, referring to the physician training he and his colleagues are doing these days. Indeed, Martich and several colleagues in IT, clinical informatics, and executive leadership in the organization began a complex process about a year ago, by first surveying thousands of doctors in the organization on their perceptions of physician documentation, and then gathering doctors together in two initial groups for activity, the first one being cardiologists.
“We went through every aspect of the note,” Martich reports. “What should be in it? What can be copied and forwarded? What shouldn’t be? We began with an in-depth discussion of the SOAP [subjective, objective, assessment and plan] format that every doctor was taught in medical school, and a discussion of how you write a progress note. And we said, “SOAP ‘2.0’ stands for ‘succinct and specific, original, accurate, and problem-oriented.’ For example, the ‘original’ part of that refers to the fact that if I’m an orthopod, I shouldn’t be copying the infectious disease doctor’s note; ‘accurate’ means that you’ve got to be proofing what you’re writing; and ‘problem-oriented’ means that we need to understand the patient by their illness.”
The first group of physicians who got involved in a first pilot in this initiative was a group of 40 attending cardiologists who, led by two cardiologists who were documentation reform champions, used classroom training and discussion to create a new kind of note in cardiology, which they called the “HVI progress note,” for “heart and vascular progress note.” The first pilot took place between October and November of 2013, and was followed up by reform work on consult notes, history-and-physical notes, and a reformed discharge summary. “Until the end of February,” Martich notes, “we were only in cardiology; but we said, gosh, it’s working so well there that we’re going to be taking the pilot to our trauma surgeons.”
The impetus for all this was very straightforward, Martich says. “We in the IT world have gotten to the point where we’ve pushed doctors to use tools, but now, it’s time for CMIOs to circle back and optimize and get them not to do ‘copy and paste and sloppy and waste’; instead,” he stresses, “you should be doing ‘SOAP 2.0,’ which means half-page-long notes, because no one’s reading your 20-page note. And because you’re not lumping in the lab tests or meds you ordered, since all that information can be found in the electronic record, right? You actually can get to the heart of the matter, and get [information to be] extractable and usable.”
From SOAP to APSO
Indeed, with regard to format, HealthEast’s Patty says that “Switching from the SOAP format to the APSO format, so that the assessment and plan are the top of the note, helps, too.” Patty goes on to say that “When someone’s reading a note, what they really want to get at is, what did you find and what are you going to do about it? That’s the assessment, what you found, and the plan—what you’re going to do about it. And switching to APSO gets that information to the top of the note. It tees the information up; it’s like reading the executive summary in a magazine article first, and then choosing what I want to read in the story.” He adds that “There are also certain things we can do to structure documents to make them more succinct. In the case of an ICU patient, for example, you could structure the document to pull in the last 24 hours' worth of laboratory values; and that could amount to several pages. So the solution there is teaching physicians to pull in just the labs they found pertinent to their note today.” The key here, he adds, is to train physicians away from pulling information and data into the note that now, in mature EHR systems, can easily remain available within a click or two, while not needing to be included in the progress note itself.
George Reynolds, M.D., CIO and CMIO at Children’s Hospital and Medical Center in Omaha, agrees completely with HealthEast’s Patty, and emphasizes that, for many physicians, part of the issue is the very recent transition to electronic documentation, from paper documentation (at Children’s, inpatient electronic documentation only went live last summer, though it had been live for several years on the outpatient side). “The EHR turns physician note-writing on its head,” he notes. “In the paper world, less was more, and you’d get the classic surgeon note that said, ‘Patient doing well, continue with above,’ and really, though billing concerns might drive more than that, the pressures of time made people perhaps too succinct. The EHR allows you to blow in all sorts of extraneous content, and obviously, with copy-and-paste and copy-and-forward, you can insert all sorts of unnecessary content.” In other words, he confirms, “Note bloat exists.”
Reynolds, like Patty, has also pushed the practicing physicians at Children’s of Omaha to shift from the “SOAP” format to the “APSO” format; and though he acknowledges that that shift in itself does not eliminate note bloat, it does at least push all the most relevant information to the top of a progress note. Then, he says, the second part of documentation reform is training the physicians to create more succinct, usable progress notes; as at UPMC, he and his colleagues at Children’s have been training their doctors to write reformed notes.
Importantly, Reynolds says there’s an element of “urban myth” regarding some of the new policy- and regulatory-driven mandates in the industry.”People have some ingrained beliefs about billing requirements and documentation requirements, so there’s an education process—not just for physicians, but for coders, as well,” he says. “And I just had this conversation with a doc, and said, you know, putting in three days’ worth of chemistry results and so on—doesn’t do anything. Commenting on the results—addressing abnormal labs, saying, I’m going to address the abnormal potassium—that’s what’s important.”
The “urban legend” around new requirements
One industry expert who is adamant about exposing the “urban myth” or “urban legend” around new documentation requirements is Mark Van Kooy, M.D., director of clinical informatics at the Pittsburgh-based Aspen Advisors consulting firm. The Philadelphia-based Van Kooy says of the documentation reform work he is currently doing with numerous hospitals and health systems, “We’re discovering that there’s a lot of urban legend generated within organizations around what really is required to meet all the requirements around the note. It’s actually both not as bad as, and yet is far worse than, what one hears. What we’ve learned,” Van Kooy says, “is that when you ask those departments that seem to be driving those requirements what they really want from the note, they don’t always want more. But when they do, they typically want some very specific items that physicians should be communicating.”
Indeed, Van Kooy continues, “When you talk to Quality, they say, just tell us what is happening with the patient, and answer those specific questions to document for those CMS [Centers for Medicare and Medicaid Services] requirements. So for example, did you document their ejection fraction for a heart failure patient (how effectively the heart is beating), or are they on a beta blocker? Most of those data elements were picked to be appropriate. Now, documenting them can be annoying, but it does have to be documented, though not every day or in every note. So we tend to take these relatively reasonable requests; and the message that physicians get is, we need more.”
Inevitably, Van Kooy says, “We hear from Quality, ‘We need this CMS indicator documented,’ like the beta blocker; we hear from the coders, ‘If you just added one more element, this note would have justified a higher level for coding’; and we hear from the utilization people, ‘If you just added this element, it would justify a longer length of stay.’ And there’s no countervailing influence [in hospitals] to make notes more readable or coherent.” The solution? Thorough training. In fact, Van Kooy says, “If you ask the residents in an academic medical center what training they got in how to write notes, they say, little to none, just training in CPOE [computerized physician order entry]. But it feels like more is better,” he notes, so untrained physicians are over-writing, leading to patient safety concerns. As a result, he is working with a variety of organizations on this very issue, to effectively end “note bloat.”
Taking this from a slightly different viewpoint, Colin Banas, M.D., CMIO at VCU Health System in Richmond, Va., notes that one problem has to do with workflow issues embedded in many EHRs. “As a physician, I’ll start a note, and I’ll pull in information from the meds list, lab values, and vital signs on a patient, and it’s not because I need them to support my billing, for example, but because I don’t want to exit the note before I forget what those things are, and selecting, highlighting, and deleting them back out is a pain. So the problem there is EHR workflow, which doesn’t work in terms of the cognitive process of writing the note,” and sometimes, that’s the issue behind what appears to be non-compliance, he says. Meanwhile, Banas says, “There are actually people who are in fact abusing the tool; but you can say that about any tool. I hate the notion that we’re going to have to turn off copy-paste or copy-forward functions” because of untrained physicians working poorly with the tools available to them. Instead, he says, “the trick is to engage in intensive monitoring, after training doctors, and indeed, in peer pressure,” post-training, to eliminate poor note-writing practices.
CIOs and CMIOs—creating the bridge
Progressive CIOs say they’re absolutely ready to partner with CMIOs to reform documentation practices. Says Daniel Barchi, senior vice president and CIO at the four-hospital Yale-New Haven Health System and at the Yale School of Medicine, all in New Haven, Conn., “There’s no way to get around what we expect out of a note, for care, for documentation, and for billing. So we can’t get away from those needs; but we can make it easier for people to use a note in the way they need to use it. And one way to do that is to make it easier for caregivers to identify patient status, and what we do next, by putting those elements at the very top of the note, literally making them what you see first when you open the note. And only then, after that, should you do all the documentation of findings, and the information to convey the level of service and other billing-related data. Interestingly, this is not so much about technology,” he says, “it’s about format, and physicians holding their colleagues accountable to be clear and concise.”
Barchi offers that, “On the back end, we’re looking at how to use NLP [natural language processing] for compliance, auditing, and coding purposes.” And, he adds, “This is absolutely a top-of-mind issue for CIOs and CMIOs.”
And what should happen between CIOs and CMIOs? There can be no better expert on that subject that Children’s of Omaha’s Reynolds, who is a dual CIO-CMIO. “The CIO-CMIO dialogue is a critical dialogue, and it’s going to be individual to the people and institution; but there has to be trust that each has the other’s back, and they understand each other,” Reynolds says. “The typical CIO is juggling the technology and infrastructure and budget; and, absent a critical discussion with a CMIO one can trust, decisions get made based on who screams the loudest or who has the most clout. So it’s the CMIO’s role to help the CIO understand what investments will result in the most value, and it’s the CIO’s role to continue to hold the CMIO accountable for that guidance. So you need to understand each other’s pain, and it’s about that learning environment between the two.”